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Low Back Pain

Intern Ambulatory BlockSusan Dresdner, M.D.

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Low Back Pain

• Lifetime prevalence of 80%• 5th most common cause for MD visits• Increasing costs without improved outcomes

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• Most due to nonspecific musculoskeletal strain, resolve within few days to weeks

• Up to 1/3 have persistent pain of at least moderate intensity 1 yr after acute episode

• 1/5 have substantial limitations in activity

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What’s associated with development of back pain?

• Obesity• Physical inactivity• Occupational factors• Depression/ other psychological conditions

• No evidence available that maintaining nl body wt and fitness, and avoidance of activities that can injure back, will decrease risk.

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Obesity

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Environmental Factors

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Work Related Pain

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Are Preventive Measures Effective at Work?

• Studies include educational interventions and mechanical supports

• No large benefits shown in primary or secondary prevention

• Large RCT of educational program for mail carriers who did or did not have previous LBP did not show any benefits

• Trial in workers with physically demanding jobs did not show benefits

• Education and lumbar suppports showed no reduction in LBP

• Evidence is also lacking for external back support (ie. belt or brace)

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Bottom Line:

Regular exercise and maintenance of fitness MAY be helpful, but evidence is insufficient to support use of any specific preventive interventions

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History and PE

Hx and PE should place patient in 1 of 3 categories:

nonspecific LBP

back pain potentially assoc with radiculopathy or spinal stenosis

back pain potentially assoc with another systemic or spinal cause

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History

• Inciting event/ trauma?• Duration• Hx systemic disease (rheumatologic, cancer,

immunocompromise)• Systemic symptoms (fever, wt loss)• Location of pain, radiation• Infectious source• Hx osteoporosis or steroid use• Bowel or bladder retention (or overflow incontinence),

LE weakness• Social hx

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Physical exam

ObservePostureGaitMuscle atrophy

PalpatePoint tenderness over muscle/ bone/ muscle

insertionsRange of motionReflexes, sensory examStrength (great toe, ankle, quadriceps)Straight leg raiseDon’t forget possibility of abdominal source/ hip

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Neurologic Exam: Nerve Roots

• L3-L4– Sensory – medial foot– Motor - knee extension (squat and rise)– Reflex - patellar

• L4-L5– Sensory – dorsal foot– Motor – dorsiflexion ankle and great toe (heel walk)

• L5-S1– Sensory – lateral foot– Motor – plantarflexion (toe walk)– Reflex - Achilles

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• Mechanical 97%– Lumbar strain or sprain >70%– Degenerative disk disease/ facet arthropathy 10%– Herniated disk 4%– Osteoporotic compression fracture 4%– Spinal stenosis 3%– Spondylolisthesis 2%

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• Nonmechanical Spinal Conditions 1%

Neoplasm 0.7%

Inflammatory arthritis 0.3%

Infection 0.01%

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Red Flags

• Hx of trauma• Systemic signs of infection• Neurological signs• Unexplained weight loss• Hx of cancer• Hx of immunosuppressants or chronic steroids• Hx of IVDU

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Imaging

• Radiographic exams are usually of limited use unless hx or PE suggest underlying cause

• Xray findings correlate poorly• Spinal imaging studies in asymptomatic

people commonly reveal bulging or herniated disks, spinal stenosis, annular tears and disk degeneration which may not be clinically relevant and reduce specificity of imaging tests

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Imaging: American College of Radiology Appropriateness Criteria

Choose test with the highest numeric rating

Clinical Scenario

Uncomplicated LBP

Low-Velocity Trauma, Osteoporosis, or age >70

Suspicion of cancer or immunosup-pression

Radiculopathy Past Lumbar surgery

Cauda Equina Syndrome

X-ray 2 6 5 3 5 3

CT without contrast

2 6 4 5 6 4*(with and without

contrast)

MRI without contrast

2 8 8 8 6 9

MRI with and without contrast

2 3 7 5 8 8

Nuclear bone scan, targeted

2 4 5 2 5 2

X-ray myelography

2 1 2 2 2 2

CT myelography

2 1 2 5 5 6

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Non-Pharmacologic Therapy